Responding efficiently to scrutiny of claims

You’ve mentioned that CMS has been scrutinizing claims much more closely lately. What does that extra scrutiny mean for RCM professionals?

Responding to ADRs can be incredibly time-consuming. We’ve found that approximately 50 percent of organizations are still using paper to transmit medical documentation to their MACs. Not only is printing and assembling this documentation a chore, but it then must be sent via FedEx or certified US mail, which can be risky, both in terms of HIPAA compliance and reliability. It’s a very cumbersome process.

Talk more about the reliability challenges when using paper.

To respond to an ADR, billers spend significant amounts of time collecting all of these paper documents, organizing and shipping them, and then in some cases they are never even received by the right party. And as everyone knows, ADRs must be responded to within a specific time frame, so if documents go missing, or are misdirected at the destination, the claim can be denied. I’ve heard from billers who have done everything right on their end, but the documents were misdirected at some point, or were sitting in the office of someone on an extended vacation, and as a result the claims were denied. And these can be very big claims. You can appeal in these cases, but the appeals process is the same—again, you have to assemble and ship the documents, and you must provide justification as to why you delayed your response.

What is the alternative to using paper?

CMS offers esMD—electronic submission of medical documentation, and ABILITY | EASE® now interfaces with the esMD gateway. EASE was already providing ADR information in the past, notifying customers when they receive ADRs. Now, a new esMD enhancement allows them to securely submit documents as well. Documentation is time-stamped when it is submitted, and users also receive acknowledgments so they know the information has been sent successfully.

In addition, EASE is able to follow the claim while it is processing in the common working file (CWF). So the application will inform users as the claim is moving along, and they can see how far it is from adjudication, and what the ultimate status is, whether paid or denied. If the claim is paid, the system will show how much has been paid. If it’s denied, you learn that as soon as possible and you can get started with the appeal using the same electronic process.

How does ABILITY determine what kind of enhancements to make to applications?

The new esMD and Analytics capabilities in ABILITY | EASE were both created with feedback from our customers and prospective customers. A big part of my role is staying in touch with EASE customers and other healthcare billing professionals to make sure we’re offering services they want and providing a strong value. So we really do have people working on the ‘front lines’ of revenue cycle management to thank for helping us continue to offer the best services, and we’re always looking at what we can create next.